How many acupuncture treatments for tinnitus

Therapy of unspecific tinnitus without organic cause

Introduction: A large number of medical and non-medical therapeutic approaches are currently in use that have not been subjected to any systematic, evidence-based testing with regard to their effectiveness.

A multitude of therapeutic approaches, medical and non-medical, try to provide relief from the various types of tinnitus. In addition to the evidence of existing medical therapeutic approaches to be clarified, the scientific literature in the field of diagnosis and classification as well as medical / psychiatric / psychological procedures should also be clarified to round off the topic.

Question: The HTA report should deal in particular with the following questions:

  1. What is the evidence of diagnostic procedures for recognizing tinnitus?

  2. Which forms of therapy show medical effectiveness for acute or chronic tinnitus without an organic cause?

  3. What consequences (need for research, future procedures) arise from these findings?

Methodology: The search term "tinnitus" was searched in the following databases:

HTA97; INAHTA; CDAR94; CDSR93; CCTR93; ME66; ME0A; HT83; SM78; CA66; CB85; BA70; BA93; EM74; IS74; ET80; EB94; IA70; AZ72; CV72; GE79; EU93; HN69; ED93; EA08

The research yielded a result of 1932 papers, unsorted, after evaluation according to the criteria of evidence-based medicine. 409 examinations were selected.

Due to the completely heterogeneous presentation of the therapeutic approaches in the treatment of chronic tinnitus, no quantitative synthesis method could be used, which is why the methodology corresponds to a qualitative review.

Results: The diagnostic methods for clarifying non-specific tinnitus without an organic cause encounter the problem of the objectivity of this tinnitus. According to the current doctrine, the stage diagnosis is also carried out in the case of subjective tinnitus. Nothing can be said about the evidence of these procedures, since no work dealt with them. In a study on the evidence of the diagnostic questionnaires, Goebel and Hiller [1] come to the conclusion that the frequently used tinnitus questionnaire (TF) [2] is the best evaluated method.

The number of therapies that are attempted to treat tinnitus is extremely large and thus makes it clear that “the” tinnitus therapy is still being sought. The current findings on the genesis of tinnitus, however, point to a multifactorial process, so there can be no standard therapy for tinnitus, but rather an adapted therapy depending on the suspected cause. The following seven broad categories can be distinguished:

Ad 1: Apparative acoustic therapies: Of the many studies on the acoustic therapy of tinnitus using apparatus, only two showed a level of evidence that allows a scientifically correct statement about the effectiveness of these procedures. There were selective significant improvements or a superiority of the tinnitus mask compared with a placebo (switched off device).

Ad 2: electrical stimulation: In an application study of electrical stimulation, the results were not statistically evaluated; it was described descriptively that successful treatment can be expected in around 50% of cases.

Ad 3: Psychological therapy methods: Hypnosis showed no positive effectiveness. With regard to biofeedback, it can be concluded that this method can be effective in individual cases, but must be regarded as unreliable due to a lack of reproducibility. Neurobiofeedback, on the other hand, was able to prove that it had a positive therapeutic effect.

Of eight controlled studies on relaxation techniques and cognitive behavioral therapy, four showed a therapeutic success (effectiveness) and four a non-effectiveness. Combined forms of therapy have generally proven to be more effective than individual forms.

Behavioral psychotherapy was able to demonstrate a positive therapeutic effect. In a study with cognitive therapy and relaxation (three groups, a passive (PRT) as well as an active relaxation (ART) and a cognitive therapy) short-term successes (for one month) could be determined, but the values ​​returned to the starting value after four months .

Likewise, only incidental and short-term successes could be achieved with cognitive behavioral therapy training, autogenic training and structured group psychotherapy.

Ad 4: Tinnitus retraining therapy (TRT): Unfortunately, the results of the TRT published so far are often methodologically poor and scientifically of little value. Many of the studies on TRT presented so far are not sufficiently conclusive in terms of their scientific significance.

In a study on 95 patients with chronic tinnitus, a significant success that was stable over a period of six months (improvement of at least ten points in the TF by means of a combined use of TRT with group behavior therapy was achieved.

Ad 5: Pharmacological therapies: Rheological drugs (drugs to thin the blood) could not show any statistically reliable effect in the treatment of tinnitus.

Studies on the treatment with tocainides (lidocaine) showed repeatable positive effects of tinnitus in higher doses (from 1.2 mg / day). Lamotrigine as a drug only had a positive effect in a small proportion of the patients. Two studies with GABA receptor agonists (GABA = gammaaminobutyric acid) could not demonstrate any therapeutic effects in tinnitus. Undesirable side effects were observed. In a special form of tinnitus, cochlear synaptic tinnitus (CST), injections with Carvoverine (a glutamate antagonist) achieved significant results.

A tricyclic antidepressant (amitriptiline) was shown to be superior to placebo. This effect could be confirmed in another study. A benzodiazepine (clonazepam), on the other hand, could not achieve any improvement. Short-term improvements have been achieved with other benzodiazepines (clonazepam, diazepam, flurazepam, oxacepam, and alprazolam).

A German retrospective study suggests graduated pharmacological therapy using rheological infusion therapy, neurotransmitter applications and lidocaine injections. This method led to a disappearance or an improvement of the symptoms in 95.3% of the acute and 26.7% of the chronic cases.

Ad 6: Surgical procedures: The effects of surgical stapes removal (stapedectomy) showed significant effects in relation to tinnitus. This method is a routine operation to restore hearing, effects on tinnitus were only "incidentally" noted.

There are generally high proportions of improvements in tinnitus after cochlear implants, but there is a risk of deterioration with this method.

Ad 7: Other and alternative therapy methods: After acute events with tinnitus consequences, hyperbaric oxygen therapy can be regarded as successful. However, the therapy should be used in the first month after the onset of tinnitus.

The methods of transcranial, electromagnetic and transcutaneous nerve stimulation showed no significant effects on tinnitus. The effects of the low laser treatment were also disappointing.

Although the authors of the study describe pneumatic external counter-pulsation as a method that can be used without problems, 10% of the patients had to discontinue the treatment because of the symptoms associated with it.

Acupuncture treatment showed significant improvements compared to a drug group in one study. The effectiveness of this form of therapy could not be proven in another study. Its results agree with those of five other studies from 1993 to 1999, which also showed no therapeutic effect. Gingko biloba preparations showed no positive effects on tinnitus in large-scale studies.

Discussion: As a rule, neither the diagnostic procedures nor the therapeutic method classes - let alone individual therapies - have the scientific validation that is common in medicine. This situation, which is highly unsatisfactory for both the patient and the practitioner, results - at least from the literature - unresolved social security, economic and legal problems.

Numerous competing models of the development of tinnitus led to an incredible creativity in trying out different therapeutic approaches. It is striking that in the last decades of tinnitus research there has been no convergence of therapy methods - on the contrary - the creativity of new approaches is increasing more and more.

Research into the causes of tinnitus should therefore be given priority, as a development of therapy methods for the treatment of various forms of tinnitus can be derived from this, so that an evidence-based treatment of the various forms of tinnitus can be initiated.

Conclusion: The innumerable therapeutic approaches, which seem completely incoherent due to their type of effect, should be tailored to the meaningfulness, the promise of success and the patient safety in the light of the most plausible explanatory models for unspecific chronic tinnitus. For this purpose, the establishment of competence centers or related science-conducting institutions are recommended.

Investigations that are also carried out on small numbers of cases often show serious methodological inadequacies. Here, too, it is required that at least the minimum requirements for a scientific clinical trial such as B. Design, sample size calculation, analytical statistics, control groups, are adhered to.

It is advisable to promote further research into the causes of tinnitus and thus to enable a targeted, evidence-based treatment of the disease.